Can a Medical Practice Actually Say No?

Can a Medical Practice Actually Say No?

By Katie O’Leary.

Many Americans do not know the difference between Medicare and Medicaid. There are a lot of programs our country has created, many of them can be even more confusing and have even more paperwork to trip you up. Just qualifying for Medicare can be a headache: you can be denied multiple times, get the wrong information, and even have go to court to receive the benefits you so desperately need. Medicare is granted 2 years after SSDI is awarded. One cannot apply for it until one reaches the mandatory retirement age, depending on one’s year of birth, or 65, whichever comes first. If you are less than 65 and receive SSDI, one may be eligible for Medicaid depending on state income thresholds. It’s not a guarantee.  Under certain conditions, say dual eligibility gained as an adult disabled child, one may be eligible for both Medicare and Medicaid. Rules and thresholds vary by state. When an American citizen turns 65 years of age, they automatically qualify for Medicare. But, if you have a disability, you can apply for Medicare and receive the same benefits at a younger age.

Such is the case with Sarah[1], a patient who qualified for Medicare after being approved for disability benefits due to her full-body CRPS. (We’ve changed her name so as not to hurt her attempts at finding a medical practice)

Katelyn O’Leary

For those who do not know, CRPS (Complex Regional Pain Syndrome) is a disorder of the sympathetic nervous system, usually triggered by an injury, surgery, accident, etc. The brain becomes confused and believes that long after an injury to a particular part of the body has healed, that the area is in fact still damaged. This results in excruciating neuropathic pain signals being sent to that part of the body, or in Sarah’s case, her ENTIRE body. It started with an injury to her shoulder from a nasty fall at her job. Unfortunately, CRPS is known to spread, and hers has spread to her other limbs and her internal organs as well. She qualified for disability in 2015 after a worker’s compensation case and has been trying to find a decent clinic and doctor to treat her disorder.

On August 22, 2018, Sarah called the Mangrove Medical Group located in Chico, CA looking for a new doctor to potentially treat her. When she asked if they take Medicare patients, they informed her that they only take patients who are 65 and older. She immediately followed up with her Medicare representative who told her this was not true – Medicare patients cannot be discriminated against or denied coverage based on age. When Sarah dug deeper, the administrator for Mangrove asked her if she was a potential pain management patient. When Sarah said yes, the administrator said “We do not prescribe opioids so that is why we do not cover patients under 65.”

I was appalled by this statement. Denying coverage to disability patients because you do not wish to treat their pain? I had to find out for myself what was going on. And what I would soon find out, is that this is happening everywhere. I called Mangrove Medical Group and asked to speak to their administrator Ann[2].

“Do you accept Medicare patients?” I asked.

“Yes we do.” She said.

“What about patients under 65 years of age?” I said.

“At this time we don’t accept patients younger than 65.” She replied.

When I told her that I was a writer she immediately hung up on me and all further attempts to contact her were sent directly to voicemail[3].

I then decided to call Medicare myself and see what they would say about this situation. Could it be true that in this day and age, with the opioid epidemic rising, and with the influx of disability patients – that doctors could deny Medicare patients who are younger? Is this a new way to restrict pain patients from taking advantage?

“I have never heard of that happening before – ever.” This was said by Diana[4], in a tone of shock, a Medicare representative I spoke to and to whom I told Sarah’s story. She informed me that not only was this illegal, but that it violated the list of rights for all covered Medicare patients:

  • Be treated with dignity and respect at all times.
  • Be protected from discrimination. Every company or agency that works with Medicare must obey the law. They can’t treat you differently because of your race, color, national origin, disability, age, religion, or sex.
  • Have your personal and health information kept private.
  • Get information in a way you understand from Medicare, health care providers, and, under certain circumstances, contractors.
  • Get understandable information about Medicare to help you make health care decisions (this list is available via medicare.gov)

Diana went on to tell me, “Notice how it says ‘be protected by discrimination’? It includes age. If a doctor had a MEDICAL reason to deny service or coverage to this patient, they would have to submit paperwork, or an ABN: ‘An Advance Beneficiary Notice (ABN), also known as a waiver of liability, is a notice a provider should give you before you receive a service if, based on Medicare coverage rules, your provider has reason to believe Medicare will not pay for the service (medicare.gov).’”

But Sarah did not receive an ABN. She was told over the phone that because she was under the age of 65, she would not be accepted as a patient at the Mangrove Medical Group. Diana then said, “She needs to file a complaint against this medical office with her local civil rights office: hhs.gov/hippa. They cannot deny her coverage based on her age. That is simply discrimination.”

I consulted Terri Lewis, Ph.D., a frequent contributor to the National Pain Report. When I asked Terri about this situation, she said, “The only way they could legitimately deny [this patient] is if they were not contracted on her insurance carrier plan. In this case, age, gender, disability are not involved. They do not have to participate in every Medicare plan.”

Terri then went on to explain something called “capitation.”  In a capitated plan, often called Advantage plans, the insurer strikes an agreement with physicians to limit the numbers of persons they have to serve so as not to overly burden the economic formula for the physician reimbursement.  Most physicians will not disclosure that they have hit their capitation limits when they tell patients they are not accepting new patients.

Furthermore, if they are accepting patients on the Medicare plan in question, then they must accept despite characteristics. If pain is in the equation they can say, “We do not treat pain.” But they must refer, and the insurer must make sure they have qualified providers for pain management on their plans. Unfortunately they can have qualified providers who are working at the limit of their capitation agreements who are not taking new Medicare patients under the plan in question. It’s a form of hidden rationing that remains undisclosed to the public. It harms patients who are complex.

A medical practice does not have to disclose capitation and could instead refer a patient to another practice. But in Sarah’s case, capitation does NOT seem to be present. They did not refer her to another doctor to treat her pain, and the economic burden of the medical practice is unclear given that they were accepting new patients. But the question I have is this: Wouldn’t it make more sense to just say they have too many patients and lie than admit to such discrimination? Most doctors usually shuffle patients to other doctors when they can’t provide a service or provide pain management due to lack of resources or simply from lack of ability. If this medical group is so ignorant and willing to reveal their discriminatory bias towards patients, and are willing to trample on the rights of patients – do they even know capitation is an option?

Ultimately, as a CRPS patient myself, I am appalled by the apparent actions of a medical group that is willing to break the law to deny service to patients with disabilities. If they wished to avoid becoming a pain management clinic, there are ways to do that without infringing upon patient rights. Sarah has already filed a complaint against Mangrove Medical Group. But I encourage every Medicare patient of ANY age to know your rights and to fight for them. You deserve treatment and you deserve to be heard. And for medical groups who are afraid of dealing with pain patients? There are other ways to avoid pain management as a specialty: it’s called not having it.

If you or a loved one feels that you are being discriminated against by a medical group, doctor, hospital, or health plan while on Medicare, please go to this website to file a claim as soon as possible: hhs.gov/hippa

Repeated attempts to further reach the Mangrove Medical Group were unsuccessful

[1] Her name has been changed to protect privacy of those involved

[2] Her name has been changed to protect the privacy of those involved

[3] All further attempts to reach the Mangrove Medical Group Administration office were unsuccessful and went to voicemail

[4] Her name was changed to protect the privacy of those involved

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Authored by: Katelyn O’Leary

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Mary

Intractable Pain is a real condition and its medical “Standard of Care” is populated in the new ICD10 database. Perform a search on “Intractable Pain” in the website http://www.icd10data.com and you will see many forms of its physical reality.

Wikipedia defines IP as Intractable pain, also known as Intractable Pain Disease or IP, is a severe, constant pain that is not curable by any known means and which causes a bed or house-bound state and early death if not adequately treated, usually with opioids and/or interventional procedures.

Yes, I can relate to both bed and house-bound state. Early death if not adequately treated with opioid therapy and other interventional procedures?

CMS Medicare/Medicaid: Why does your federal agency fail to pay for physician administered Acupuncture? Why ignore our physical pain?

Oldgoat

Great article, Katie. Excellent job on knowing just who to call to get the facts and digging down in to the weeds for the details.

Gretchen

From a fellow disabled and pain paitient I sorry this is happening too any pain paitients I havent had this particular thing happen but we are all facing big challenges that are discriminating and humiliting I went too pain managment the other day was called back by the receptionist with 5 other paitients too what is the surgical room for. Epidural shots we had a curtain separating us from each other no private office room we could hear all that was being said too every paitient in the room no privacy did not appreciate that and on top of that I had 8 transdermal shots the month before which gave me no relief from pain and had caused more pain and problems I told the nurse what was going on when it came my time too be talked too the Dr asked me if I was ready too wean off all my medications and told me the transdermal shots caused me none of the problems I said had happened this Dr seems too be unapproachable if something goes wrong there is no talking too him It all scares me that the Dr has no respect for privacy or can not be talked too without threatening too take away the lesser than what I need already medications that the state of Ohio says I’m allowed too have what a crock and violation of our rights I Guess we have none these judgers will be hurting when carma knocks of their door for what they are doing too the most variable of Americans Sorry too all and I will pray for all that we will survive medically and mentally from all the abuse we are enduring WILL IT EVER STOP or is it going too kill us all????? There is no safe feeling or well being for any of us and adding too our already terrible problems stress can kill you alone without all the unexceptable practices that are now part of our lives what a nightmare waiting too die a lot sooner than we all need too there is no peace of mind

kelly

I also am starting to experience issues. I am the current benefactor of receiving bad health care due to my long term health providers retiring. After being with a pair of doctors that treated me for well over 20 years they both retired within a year of each other. That left me with a daunting task of getting a new pain management doctor and Primary care. What a quest it has become. In small rural areas there just is not enough doctors. I found a PC that was willing to handle my pain management and things were fine for a year. He was part of a federally funded clinic. Without much notice he left to join another practice. Basically all the pain management patients were not given direction nor referral to valid pain management doctors. The director and other members of the clinic were not even responding to emails regarding who would be taken over this doctors patients. The run around I was given was just insane. Trying to find another pain management doctor and many want big bucks upfront for you just to start. I went on a quest at this point to find out why and how this could happen. I wrote our Governor many times and finally got an answer. This is not suppose to be happening. His recommendation was for me to call my local health department. I followed through and got them involved. I wanted answers. They were very helpful and set up a patient liason and even got in touch with the clinic and director. I then spoke with the Director of the Health Department at length to get some insight as to why chronic pain patients were being pushed out and not able to get medications that they needed. This is a problem not as of yet has not been addressed. The Opioid Crisis center of attention is focused on addicts and controlling opioid flow and has left chronic pain patients on the sideline. Why are we being treated so badly when we are the ones that are following the laws, not breaking them? It is a challenge, but one that each of us must take on to get the care we deserve. Yes that you deserve. Report these doctors that are not giving you the care you need. Contact the Board of Physicians and file complaints. Do not allow anyone to hold you hostage or silence you by the threat of withholding treatment or medications. That is what these doctors are banking on-SILENCE of what is really going on out there.

Maureen M.

A couple of years ago I was searching for a new primary doc. I called a recommended office. They said they do accept my Medicare. The woman then asked the next question…’do you take opioids?’ I said ‘yes, I do happen to but I am in Pain Management for that and therefore I am not interested in your doctor having to prescribe them.’
Well, she said ‘well then , we cannot accept you as a new patient since you are taking opioids’. I reiterated what I had just said to her and she could not hang up on me fast enough!! She refused to accept me as a new patient!! I cried. I felt so dirty and discriminated against just because I am a CP person who takes pain meds.
Folks, we truly are decriminated against and that too ought to become part of our momentum in fighting for our patient rights!

Steven

The pain paitent has not had any rights since the governmental takeover of 1/1/14. I can tell you that from first hand experience . I have experienced it in all 5 states I have lived in since. No enforcable rights anyhow. Our government has already eliminated most PAIN PAITENTS lives and now what you hear are the last few cries of help I am dying from the sparse remainder. Myself included. Sadly, the doctors of this country have just sat back and let it happen. IT IS FORCED TORTURE BY FORCED TAPER AND THEN THE INEVIATABLE FORCED SUICIDE. GENOCIDE!!!

Katie Olmstead

What a timely piece for me. I happen to have the world’s most wonderful primary care physician. He is my rock. I also have CRSP. But MassHealth, aka Medicare, is making my life nuts. I have noted this website. One of my basic pain meds is now being denied coverage. I don’t have extra cash sitting around to pay full price, though I have been. I have gotten an incredible run around while attempting to request a hearing. My own doc is pulling his hair out and screaming along with me. How dare they make medical decisions that are set between him and his patient? They are administrators, not MD’s, and in any case I am not THEIR patient. This has been going on now for 8 months. It it getting old. So am I.

Stephen

Hi, I have been on opioids for four years before and after neck surgery. In Riverside County, Ca, you cannot buy Percocet right now,of any formulation, because of the 20% production decrease mandated by the fda. I am lucky enough to have a doctor who was willing to prescribe another opioid as a replacement. But I fear for the majority of patients who will not be so lucky. Some will be forced to the streets while drug rehab in this republican stronghold is not easily accessed unless you have money. There will be a lot of misery in SoCal this week and the months to come.

Jodawn

One of the best, most informative, articles I’ve read on the subject!
Thank you!!!

David M.

It isn’t just NO that these doctors are saying. I can tell you first hand that they also make your visits so onerous and threaten you that if you fail to meet their stipulations or stipulations in your pain contract something that pain management doctors often require that they will have no choice but to drop you as a patient. They make the physical and financial burden so great knowing that you are on a fixed income and limited in your ability to fight back since it takes everything you have to just manage taking care of yourself each day managing CRPS the most painful disease known to exist that you won’t be able to meet these stipulations and they can drop you citing this so you can’t accuse them of discriminatory practices.

#CRPS #ChronicPain